Ischemic Heart Disease Flashcards
What is the leading cause of death in adults in the United States, accounting for about one-third of all deaths in subjects over age 35?
Coronary Artery Disease
What are the risk factors for CAD? (7)
Age
HTN
Smoking
Elevated Cholesterol
Diabetes
Family history
Obesity
What term is applied to patients in whom there is a suspicion of myocardial ischemia?
Acute Coronary Syndrome
What are the types of acute coronary syndrome? (3)
ST elevation (formerly Q-wave) MI (STEMI) Unstable angina (UA) Non-ST elevation (formerly non-Q wave) MI (NSTEMI)
What is a clinical event consequent to the death of cardiac myocytes (myocardial necrosis) that is caused by ischemia?
Myocardial Infarction
What is the criteria for a myocardial infarction? (4)
Rise and fall of cardiac biomarkers
EKG changes
New wall motion abnormalities
Symptoms of ischemia
What patients may not realize that they have had an MI?
Diabetes due to neuropathy, perhaps.
What types of therapy can be used for CAD? (2)
Anti-anginal therapy
Preventative therapy
What are anti-anginal therapies? (3)
Beta-Blockers
Calcium Channel Blockers
Nitrates
Should nitrates be skipped in the evening or in the morning?
They should NOT be skipped in the evening!
What are preventative therapies for CAD? (3)
Antiplatelet therapy
Risk reduction
Statins
Should you ever give ASP with ibuprofen?
If ASP taken first thing in the morning, then ibuprofen much later, then OK.
What are the methods to treat CAD?
PCI
Surgical
What is the difference between bare metal and drug eluting stent?
Bare metal stents are susceptible to inflammation.
Drug eluting never get inflammation, but need to stay on antiplatelet therapy for life.
What is the failure of the heart to maintain a cardiac output sufficient to meet the metabolic demands of the body?
cardiac failure
What is the equation for cardiac output?
stroke volume * heart rate
Define the following NYHA Class Symptoms:
I
II
III
IV
I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest.
IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
Define the following Canadian Cardiovascular Society Angina Grading Scales:
I
II
III
IV
Class I – Angina only during strenuous or prolonged physical activity
Class II – Slight limitation, with angina only during vigorous physical activity
Class III – Symptoms with everyday living activities, i.e., moderate limitation
Class IV – Inability to perform any activity without angina or angina at rest, i.e., severe limitation
What are modified major Framinham clinical criteria for the diagnosis of heart failure? (8)
Paroxysmal nocturnal dyspnea
Orthopnea
Elevated jugular venous pressure
Pulmonary rales
Third heart sound
Cardiomegaly on chest x-ray
Pulmonary edema on chest x-ray
Weight loss 4.5 kg in five days in response to treatment
What are modified minor Framinham clinical criteria for the diagnosis of heart failure? (7)
Bilateral leg edema
Nocturnal cough
Dyspnea on ordinary exertion
Hepatomegaly
Pleural effusion
Tachycardia (heart rate 120 beats/min)
Weight loss 4.5 kg in five days
How can heart failure be diagnosed according to the Framinham criteria?
The diagnosis of heart failure requires that:
2 major or
1 major and 2 minor criteria cannot be attributed to another medical condition.
What are the causes of cardiac failure? (6)
Ischemic
Alcoholic
Infectious
Inflammatory
Congenital
Valvular
KNOW
What are the causes of cardiac failure relating to circulation? (5)
Heart Rate–too fast, too slow
Rhythm–ventricular (ICD), supraventricular (ablation)
Pre-load
After-load
Contractility
What can treat intraventricular conduction delay?
Cardiac resynchronization therapy - CRT
CRT uses a special pacemaker to contract both Right and Left ventricle.
What will 30% of pts with CHF have?
What changes will occur with the EKG?
asynchronous contractions of the right and left ventricle
wide QRS
What is myocardial or myocyte fiber length just prior to contraction equivalent to compliant stretch?
Pre-load
Basically, preload = _______.
volume
What can impair venous return? (4)
Hemorrhage
Dehydration
Vascular occlusion
Increased intra-thoracic pressure
What is after-load? (5)
the tension produced by the heart in order to contract
pressure created in order to eject blood out of chamber
related to “wall stress”
RESISTANCE TO FORWARD FLOW
excessive arterial blood pressure
What is contractility? (4)
intrinsic ability of a cardiac muscle fiber to contract at a given fiber length
Augmented and impaired by many components
Inotropic refers to contractility
Lusitropic refers to relaxation
What is an acquired form of cardiomyopathy? (3)
ETOH
Sepsis/Viral
Catecholamines
Contractility can be adversely affected by what? (2)
ischemia
cardiomyopathy
What will you notice on the physical exam for someone suffering from cardiac failure? (7)
Coughing
Pleural effusion
Swelling in abdomen
Tiredness
SOB
Pulmonary edema
Swelling in ankles and legs
What will you notice in the extremeties on the cardiac exam? (2)
cool extremeties
mottling
What do we need to know about S3 sounds?
may be normal
abnormal
Note: The pathologic S3 indicates decreased compliance of the ventricles, as in CHF and may be the earliest sign of heart failure
What are blood tests we can use to monitor cardiac failure?
Cardiac enzymes
Acid production
Venous blood
Normal aerobic metabolism produces a small amount of extra acid that can be measured in the blood as lactic acid or lactate.
What is a normal lactate level?
< 2
Note: Lactate > 10 usually means death is imminent.
Lactate is a global, not local, indicator. True or false?
Lactate drawn serial can guide therapy. True or false?
Both are true
What may cause a decrease in venous saturation? (4)
Decreased arterial saturation
Decreased hemoglobin
Decreased cardiac output (oxygen delivery)
Increased consumption
What may cause an increase in venous saturation? (2)
Increased arterial saturation (100% O2)
Decreased extraction
- Sepsis
- Liver failure
Where is venous blood (mixed venous) is best obtained?
Where is second best?
from the distal port of a pulmonary artery catheter
central line
What information can the arterial line provide? (2)
Preload (Pulse pressure variation)
Cardiac output
- Pulse power
- Pulse contour
What information can the CVP provide? (2)
venous blood gas
pressure (preload)
What information can the PA catheter provide?
Venous blood
Cardiac output by thermodilution
What are the catecholamines? (4)
Epinephrine
Norepinephrine
Dopamine
Dobutamine
What is milrinone?
Phosphodiesterase inhibitors
What are the vasodilators? (4)
Nitropruside
Nitroglycerine
Nicardipine
Sildenafil
What is inhalational therapy for cardiac failure? (3)
NO (nitric oxide)
Milrinone
Epoprostenol (Flolan)
What is epinephrine? (3)
Dose dependant alpha/beta agonist
Increasing alpha with increasing dose
Indications:
- Low cardiac index
- low blood pressure
- anaphylaxis
What is norepinephrine? (3)
Dose dependant alpha/beta agonist
Increasing beta with increasing dose
Indications:
- Vasodilation with decreased contractility
What is dopamine? (4)
Alpha/beta/dopaminergic
Dose dependant and variable
Cardiologists favorite drug (lousy epinephrine)
“renal dose dopamine
What is dobutamine? (3)
Synthetic catecholamine
Pure Beta
Indicated in heart failure not as bad as may require epinephrine
What is milrinone? (3)
“inodilator”
Increases contractility synergistically with the catecholamines
Indicated in heart failure with increased systemic vascular resistance
What is HOCM? (4)
Hypertrophic cardiomyopathy
Asymmetric septal hypertrophy
Dynamic outflow tract obstruction
Systolic anterior motion (SAM)
Treatment is B-blocker, fluids, increase in SVR
How do you treat SAM?
Tight, slow, full
What are the 2 types of VADS?
Heartmate I and II
Heartware
What are mechanical pumps? (2)
IABP
Impella
Mechanical is better.
CAD is a common and serious condition that has extensive morbidity and mortality. True or false?
true
Treatment is aimed at symptom control and prevention of subsequent myocardial infarction.
Treatment is: (3)
medical/stenting/surgical
CHF is always ischemic. True or false?
False.
CHF is a common condition with ischemic and non ischemic causes.
Mechanical therapy is superior to medical therapy in certain situations. True or false?
true
